Sustainment of Standardized Cardiac OR

to Intensive Care Unit Transfer of Care

Tracie Northway, RN, MSN, CNCCP(C) & Lisa Yarske, RN, BSN, CNCCP(C)

Identification of a problem

•Condition of cardiac patients upon receipt was historically unstable

•Cluster/flock care•Chaos•Delays in care•No clear communication•Missed critical information

0

20

40

60

80

100

120

140

160

180

# of

Pat

ient

sSurgical Service

BCCH PICU Surgical Admission Breakdowns (2008)

Creating change: Take 1

•New additions to CVS team•Questioning of current practice

at BCCH•Review of cardiac program•Team reps to Philadelphia for

review of practices•Team agreed on new approach for admissions•Ideas implemented

http://blog.svconline.com/briefingroom/wp-content/uploads/2008/09/childrens-hospital-of-philadelphia-37.jpg

Results of Take 1

http://2.bp.blogspot.com

Take 2: imPROVE with Lean

• Capitalized on region wide Lean improvement process• Appeal of better understanding with prep• 1 week of dedicated collaborative improvement time• Stakeholders wanted change

What were we trying to improve?

•Decrease barriers (defects in Lean language) to increase clarity within roles for a safe handover between OR & PICU Teams

•Prior to improvement week the following “defects” were observed in cardiac OR to PICU handover

Defects in Cardiac OR to ICU Transfer of care

14

8 7

14 2 1

2

3

5 12

1

3

3

21 2

11

3

3

11

1

3

12

1

2

0

5

10

15

20

25

30

Defect Category

# of

Def

ects

OR Admit #6OR Admit #5OR Admit #4OR Admit #3OR Admit #2OR Admit #1

RPIW #4 Team & Plan

Team –

Plan for the RPIW #4 week (March 23rd-27th, 2009)1. Determine characteristics of a safe patient handover from OR 4 to PICU 2. Define process, roles & responsibilities (“standard work” in Lean

language) for a safe patient handover3. Create tools to guide & support standard work4. Test standard work tools

PICU RepsAndrea Yuel (RN)Lisa Yarske (CNL)Tracie Northway (Q&SL)

OR #4 RepsBill Cooper (Anaesth Assist)Clayton Reichert (Anaesthetist)Melanie Ganshorn (CRN)Neil Casey (Perfusionist)

External RepsAlecia Robin (imPROVE)Barb Fitzsimmons (VP BCCH)Erin Miller (Executive Assistant Corporate)

Sponsor – Lynn Coolen Program Manager, PICU

Standard work

•Used past cardiac OR project work, Great Ormond’s Street handover protocol & participants ongoing input to define:–Pre-transfer standard work: •PICU bed preparation•PICU bedspot set-up•Perfusionist’s report & confirmation of PICU admitting team

–Transfer standard work:•Transfer process•Technology transfer process•Handover process

Support tools

Support tools

Support tools (cont’d)

Measured Outcomes

BCCH PICU & Cardiac OR Pre & Post RPIW Defects per Handover

4.2

2.8

1.5 1.51.2 1.3

0.7

00.3

1.3

0 0 0 00.00.5

1.01.5

2.02.5

3.03.5

4.04.5

Type of Defect

# of

Def

ects

Pre RPIW Average/Handover

Post-Kaizen Average/Handover

Measured Outcomes

•Broke down barriers & “sacred cows” between OR & PICU teams

•Developed a better understanding & appreciation for our teams and the work they do

•Determined characteristics of a safe patient handover•Defined standard work for a safe patient handover•Created & tested tools for standard work (Bedside Set-up Visual, Handover Checklist & Interprofessional Handover Protocol)

Sacred

X You actually know what’s going on [with

your patient]!

Quote from PICU CRN after participating in standard work of safe patient handover.

Workshop Summary

Follow On

•Responsive adjustment of Handover Protocol based on practice changes

•Anecdotal comments support change

•PICU staff have requested change in process for handover with other surgical services teams

http://www.dagami.com/wp-content/uploads/2011/08/big-dog-little-dog.jpg

Follow On Results: Two Years Post Change

• Black, J. & Miller, D. (2008). The Toyota Way to Healthcare Excellence: Increase Efficiency and Improve Quality with Lean. Health Administration Press, Chicago

• Catchpole, K., Leval, M., McEwan, A., Pigott, N., Elliott, M., McQuillan, A., MacDonald, C., & Goldman, A. (2007). Patient handover from surgery to intensive care: Using Formula 1 pit-stop and aviation models to improve safety and quality. Pediatric Anaesthesia, 17: pp. 470-478.

• Ohno, Taiichi. (1988). The Toyota Production System: Beyond Large-Scale Production. Portland, Oregon: Productivity Press

References